Appendix A. CJRR Phase IV Penetration Improvement Report

Penetration Improvement Report

Quarter 4, 2013 – Quarter 3, 2014

California Joint Replacement Registry

CHCF Grant #18078

This report describes CJRR’s efforts to date to analyze the penetration volumes at participating sites and develop and implement action plans to improve penetration where needed. One of CJRR’s 2014 objectives was to grow the registry both in terms of number of participating hospitals and participation at each site in order to achieve critical mass and have meaningful benchmarks for reporting. There were three major activities during 2014:

Analysis of Patient Participation Volumes and Surgeon Penetration
Development and Implementation of Action Plans
Analysis of Progress to Date and Next Steps

Analysis of Patient Participation Volumes and Surgeon Penetration

CJRR staff collected data for a penetration analysis of surgeon participation and patient registration for all hospitals that have been live with the registry for at least six months. Baseline data was collected in Quarter 4, 2013. Nine hospitals were live for at least six months; see Table 1 below for the baseline penetration numbers. To determine the appropriate denominator for surgeon penetration, CJRR asked each hospital to report the total number of eligible surgeons and compared this to the number of surgeons participating in CJRR. CJRR’s data showed that two hospitals had very low surgeon penetration and one more hospital just met the minimum criterion of 50%. For patient participation, CJRR calculated a quarter of the annual OSHPD volume for the denominator and compared this to the registration volume for a given quarter. Six hospitals had lower than 50% registration volume

Table A1: Baseline surgeon participation and patient registration data from Quarter 4, 2013; sites with less than 50% penetration are highlighted in red.

Site / # Eligible Surgeons / # Participating Surgeons / % Surgeon Participation / OSHPD Quarterly Volume / CJRR Quarterly Volume / % Patient Participation
H & C / 20 / 19 / 95% / 208 / 75 / 32%
N / 11 / 4 / 36% / 355 / 94 / 23%
L / 39 / 8 / 21% / 354 / 174 / 70%
A & D / 22 / 22 / 100% / 308 / 98 / 29%
I / 10 / 7 / 70% / 118 / 129 / 99%
M / 12 / 12 / 100% / 312 / 53 / 30%
G / 12 / 9 / 75% / 268 / 131 / 43%
Site Enrolled After Pilot Period / 11 / 2 / 18% / 241 / 37 / 19%
E / 3 / 3 / 100% / 123 / 146 / 113%*

*Note that a site can have greater than 100% patient participation since the denominator is based on an annual number and there is variation among quarters.

In July 2014, CJRR conducted a second analysis to see if there were additional hospitals that had been live for six months and should be added to the penetration analysis. Four sites were added to the analysis. At this point, CJRR also conducted a preliminary analysis of the impact of first phase interventions; those findings are described in Section 3 below.

Table A2: Surgeon participation and patient registration data from Quarter 2, 2014; sites with less than 50% penetration are highlighted in red, sites with no improvement from baseline are highlighted in yellow, and sites with an improvement since Q3, 2013 are highlighted in green.

Site / # Eligible Surgeons / # Participating Surgeons / % Surgeon Participation / OSHPD Quarterly Volume / CJRR Quarterly Volume / % Patient Participation
H & C / 20 / 20 / 100% / 208 / 75 / 41%
N / 11 / 5 / 45% / 355 / 94 / 18%
Site Enrolled After Pilot Period / 12 / 12 / 100% / 121 / 63 / 56%
J / 8 / 6 / 75% / 169 / 79 / 67%
L / 39 / 26 / 67% / 659 / 351 / 77%
A & D / 22 / 22 / 100% / 349 / 333 / 61%
I / 10 / 8 / 80% / 136 / 129 / 95%
F / 5 / 5 / 100% / 266 / 47 / 29%
M / 12 / 12 / 100% / 312 / 53 / 27%
B / 4 / 4 / 100% / 134 / 49 / 39%
G / 12 / 9 / 75% / 268 / 131 / 42%
Site Enrolled After Pilot Period / 11 / 2 / 18% / 241 / 37 / 5%
E / 3 / 3 / 100% / 123 / 146 / 96%

Development and Implementation of Action Plans

CJRR decided to first work on the hospitals with low surgeon participation given the assumption that higher patient registration volumes should result from more participating surgeons. Working with the Chair of the Steering Committee, CJRR engaged the Surgeon Champions at two sites and asked them to promote the registry to their colleagues and encourage them to participate. This initial outreach had mixed results. One surgeon joined the registry at one hospital, but no new surgeons joined at the other.

During Quarter 2, CJRR worked with the staff and surgeons at two more sites in an attempt to increase surgeon participation. As a result, one hospital engaged a second medical group to join the registry and 100% of the eligible surgeons at this hospital now participate; in addition, patient registration volume grew from 16% to 56% in one quarter. The second hospital also added two surgeons to the registry. During these discussions, CJRR staff also discussed work flow issues and explored opportunities to improve patient engagement. As a result, the patient volume increased from 37% to 67% at this hospital in the next quarter.

In an effort to address participation issues more broadly, CJRR staff decided to combine the penetration improvement work with efforts to improve PRO response rates and encourage sites to use CJRR data. CJRR staff developed summaries for the Steering Committee Chair and Co-Chair that showed which sites had low penetration, low PRO response rates and whether that site had accessed the CJRR benchmarking reports. CJRR reviewed these analyses with the Chair and Co-Chair and requested that they either call or plan a site visit to these hospitals. These hospitals were also grouped geographically in hopes of creating an opportunity for either surgeon lead to do a regional trip and meet with multiple sites. To date, the Chair and Co-Chair have emailed and called their surgeon colleagues at these hospitals and these conversations have helped to elucidate the cultural and logistical issues that underlie the participation issues.

CJRR’s surgeon leadership have also presented to the orthopedic departments of several hospitals that have recently joined the registry; the objective was to encourage surgeon participation and promote the importance of collecting PROs. In addition, CJRR scheduled three user group sessions to educate sites about how to increase their surgeon and patient engagement, how to improve their patient-reported outcomes survey response rates, and how to interpret and use their quarterly benchmarking reports.

Analysis of Progress to Date and Next Steps

CJRR has worked with several hospitals to improve their surgeon participation and patient registration volumes. As of September 30th, six sites have increased their surgeon penetration: 3 sites have added one surgeon, one site added two surgeons, one site added a second medical group, and one site added 18 surgeons.

Note that two hospitals were not included in the Q3 2013 analysis since these sites had not been live for 6 months. However, CJRR worked with both these hospitals during Q1 and Q2 2014 to improve their surgeon participation. The complete patient registration volume data is available in Table A3 below.

In addition, CJRR worked with five sites to improve their patient engagement. Patient registration volumes for all quarters is shown in Table A3; the timeframe for measuring the effectiveness of these interventions is from either Q4 2013 or Q1 2014 to Q2 2014.

CJRR staff conducted work flow seminars with staff at two sites. Both sites showed a significant improvement (20 – 36% increases from Q1 to Q3 2014) in their patient registration volumes.

The CJRR Chair talked with the Surgeon Champions at two hospitals and CJRR staff shared expertise about ways to engage patients and increase patient volume. As a result, the registration volume at one site increased from 29% to 96% (Q4 2013 to Q3 2014).

CJRR staff worked with a fifth site to provide reports so that the Site Leader could actively monitor the registration volumes of each registrar and identify performance issues. This site is has not shown any improvement to date.

These efforts resulted in increased surgeon participation at six hospitals, although the participation rate at Site N is still below 50%. Despite several outreach efforts by both CJRR staff and the Chair, and a presentation to the orthopedic department by the Surgeon Champion at one site, the surgeon participation at this site has not improved. CJRR has seen improvements in patient registration volumes as a result of both greater surgeon participation and direct efforts to address work flow issues at six hospitals (highlighted in green in Table A2; includes the two hospitals that joined after the baseline analysis). However, there was modest to no improvement at four hospitals (highlighted in yellow in Table A2).

CJRR concludes that efforts to engage surgeons and hospital staff is likely to improve surgeon and patient participation but sometimes the cultural issues at a particular hospital make it difficult to implement effective and consistent work flows or to unite a department of geographically dispersed surgeons. CJRR recommends continuing to schedule surgeon leaders to meet with the orthopedic departments when the site is ready to go live with the registry. This has proven to help with surgeon engagement and is particularly important for buy-in with future public reporting. CJRR also recommends continuing outreach to hospitals with low participation, especially those that are new to the registry and have not yet been approached. Finally, CJRR recommends continuing to convene sites for webinars to improve their PRO response rates; there is also an opportunity for surgeon leaders to promote this with their peers so that office and hospital staff prioritize this important work.

Table A3: Quarterly patient registration volume penetration from Q3 2013 – Q3 2014.

Site Name / OSHPD Quarterly Volume / Q3 2013 Penetration / Q4 2013 Penetration / Q1 2014 Penetration / Q2 2014 Penetration / Q3 2014 Penetration
H & C / 208 / 44% / 32% / 28% / 41% / 36%
N / 375 / 22% / 23% / 16% / 18% / 17%
Site Enrolled After Pilot Period / 121 / 0% / 6% / 16% / 56% / 52%
J / 169 / 0% / 25% / 37% / 67% / 57%
L / 659 / 59% / 70% / 80% / 77% / 80%
A & D / 349 / 40% / 29% / 34% / 61% / 96%
Site Enrolled After Pilot Period / 37 / 0% / 0% / 24% / 62% / 75%
Site Enrolled After Pilot Period / 157 / 0% / 0% / 3% / 38% / 68%
Site Enrolled After Pilot Period / 85 / 0% / 0% / 1% / 70% / 104%
I / 111 / 89% / 99% / 95% / 95% / 132%
F / 266 / 5% / 5% / 12% / 29% / 18%
K / 137 / 0% / 2% / 6% / 4% / 2%
M / 149 / 27% / 30% / 22% / 27% / 21%
B / 134 / 24% / 44% / 49% / 39% / 38%
G / 315 / 43% / 43% / 42% / 42% / 35%
Site Enrolled After Pilot Period / 230 / 17% / 19% / 15% / 5% / 6%
Site Enrolled After Pilot Period / 89 / 0% / 0% / 0% / 30% / 60%
E / 145 / 99% / 113% / 110% / 96% / 107%

Appendix B. Risk Factor and Complication Diagnosis Inclusion Criteria

ICD-9-CD Diagnosis Code Range Start / ICD-9-CD Diagnosis Code Range End / ICD-9-CM Description / CJRR Condition / CJRR Condition Type
042 / Human immunodeficiency virus (hiv) disease / Immunocompromised / Risk Factor
079.53 / Human immunodeficiency virus type 2 [hiv-2] / Immunocompromised / Risk Factor
250.00 / 250.93 / Diabetes mellitus / Diabetes Mellitus / Risk Factor
278.00 / Obesity unspecified / Obesity / Risk Factor
278.01 / Morbid obesity / Obesity / Risk Factor
279.00 / Hypogammaglobulinemia, unspecified / Immunocompromised / Risk Factor
279.01 / Selective IgA immunodeficiency / Immunocompromised / Risk Factor
279.02 / Selective IgM immunodeficiency / Immunocompromised / Risk Factor
279.03 / Other selective immunoglobulin deficiencies / Immunocompromised / Risk Factor
279.04 / Congenital hypogammaglobulinemia / Immunocompromised / Risk Factor
279.05 / Immunodeficiency with increased IgM / Immunocompromised / Risk Factor
279.06 / Common variable immunodeficiency / Immunocompromised / Risk Factor
279.09 / Other deficiency of humoral immunity / Immunocompromised / Risk Factor
279.10 / Immunodeficiency with predominant t cell defect unspecified / Immunocompromised / Risk Factor
279.11 / Digeorge's syndrome / Immunocompromised / Risk Factor
279.12 / Wiskott aldrich syndrome / Immunocompromised / Risk Factor
279.13 / Nezelof's syndrome / Immunocompromised / Risk Factor
279.19 / Other deficiency of cell mediated immunity / Immunocompromised / Risk Factor
279.2 / Combined immunity deficiency / Immunocompromised / Risk Factor

Appendix C. ICD-9 Diagnosis Codes that Trigger Patient-Specific Data Capture for Clinic/ED Visits

Complication / ICD-9-CM Diagnosis Code / Code Description
Wound Infection / One or more of the following codes:
682.6 / Cellulitis and abscess of leg except foot
686.9 / Unspecified local infection of skin and subcutaneous tissue
891.0 / Open wound of knee leg (except thigh) and ankle without complication
891.1 / Open wound of knee leg (except thigh) and ankle complicated
891.2 / Open wound of knee leg (except thigh) and ankle with tendon involvement
894.0 / Multiple and unspecified open wound of lower limb without complication
894.1 / Multiple and unspecified open wound of lower limb complicated
894.2 / Multiple and unspecified open wound of lower limb with tendon involvement
996.66 / Infection and inflammatory reaction due to unspecified device implant and graft)
998.51 / Infected postoperative seroma
998.59 / Other postoperative infection
998.6 / Persistent postoperative fistula not elsewhere classified
998.83 / Non-healing surgical wound
AND one or more of the following codes:
V43.64 / Hip joint replacement
V43.65 / Knee joint replacement
V43.69 / Other joint replacement
Excessive Bleeding / 719.15 / Hemarthrosis involving pelvic region and thigh
719.16 / Hemarthrosis involving lower leg
998.11 / Hemorrhage complicating a procedure
998.12 / Hematoma complicating a procedure
Fracture / 996.44 / Peri-prosthetic fracture around joint implant
Dislocation / 996.42 / Dislocation of prosthetic joint
Nerve Injury / 956.0 / Injury to sciatic nerve
956.1 / Injury to femoral nerve
956.2 / Injury to posterior tibial nerve
956.3 / Injury to peroneal nerve
956.4 / Injury to cutaneous sensory nerve, lower limb
956.5 / Injury to other specified nerves of pelvic girdle and lower limb
956.8 / Multiple nerves of pelvic girdle and lower limb
956.9 / Unspecified nerve of pelvic girdle and lower limb
DVT - Any / 415.11 / Iatrogenic pulmonary embolism and infarction
415.12 / Septic pulmonary embolism
415.19 / Other pulmonary embolism and infarction
453.40 / Acute venous embolism and thrombosis of unspecified deep vessels of lower extremity
453.41 / Acute venous embolism and thrombosis of deep vessels of proximal lower extremity
453.42 / Acute venous embolism and thrombosis of deep vessels of distal lower extremity
453.50 / Chronic venous embolism and thrombosis of unspecified deep vessels of lower extremity
453.51 / Chronic venous embolism and thrombosis of deep vessels of proximal lower extremity
453.52 / Chronic venous embolism and thrombosis of deep vessels of distal lower extremity
453.9 / Embolism and thrombosis of unspecified site
DVT - Proximal / 453.41 / Acute venous embolism and thrombosis of deep vessels of proximal lower extremity
453.51 / Chronic venous embolism and thrombosis of deep vessels of proximal lower extremity
Pulmonary Embolism / 415.11 / Iatrogenic pulmonary embolism and infarction
415.12 / Septic pulmonary embolism
415.19 / Other pulmonary embolism and infarction
Myocardial Infarction / 410.00-410.02 / (Acute myocardial infarction of anterolateral wall)
410.10-410.12 / (Acute myocardial infarction of other anterior wall)
410.20-410.22 / (Acute myocardial infarction of inferolateral wall)
410.30-410.32 / (Acute myocardial infarction of inferoposterior wall)
410.40-410.42 / (Acute myocardial infarction of other inferior wall)
410.50-410.52 / (Acute myocardial infarction of other lateral wall)
410.60-410.62 / (True posterior wall infarction)
410.70-410.72 / (Subendocardial infarction)
410.80-410.82 / (Acute myocardial infarction of other specified sites)
410.90-410.92 / (Acute myocardial infarction of unspecified site)
CHF / 428.0 / Unspecified congestive heart failure
428.1 / Left heart failure
428.20-428.23 / (Systolic heart failure)
428.30-428.33 / (Diastolic heart failure)
428.40-428.43 / (Combines systolic and diastolic heart failure)
428.9 / Heart failure unspecified
Arrhythmia / 427.0 / Paroxysmal supraventricular tachycardia
427.1 / Paroxysmal ventricular tachycardia
427.2 / Paroxysmal tachycardia unspecified
427.31 / Atrial fibrillation
427.32 / Atrial flutter
427.41 / Ventricular fibrillation
427.42 / Ventricular flutter
427.5 / Cardiac arrest
427.60 / Premature beats, unspecified
427.61 / Supraventricular premature beats
427.69 / Other ventricular premature beats, contractions or systoles
427.81 / Sinoatrial node dysfunction
427.89 / Other cardiac dysrhythmias (rhythm disorders coronary sinus, ectopic, nodal and wandering atrial pacemaker)
427.9 / Cardiac dysrhythmia unspecified
Renal Failure / 584.5-584.9 / Acute renal failure
585.1-585.9 / Chronic kidney disease
586 / Renal failure unspecified
Other Complications / 682.9 / Cellulitis and abscess of unspecified sites
719.10 / Hemarthrosis site unspecified
957.1 / Injury to nerves other specified.
957.8 / Multiple nerves in several parts
957.9 / Injury to nerves unspecified site
996.41 / Mechanical loosening of prosthetic joint
996.43 / Broken prosthetic joint implant
996.47 / Other mechanical complication of prosthetic joint replacement
996.49 / Other mechanical complication of other internal orthopedic device, implant, and graft
996.78 / Other complications due to other internal orthopedic device implant and graft
996.79 / Other complications due to other internal prosthetic device implant and graft
998.13 / Seroma complicating a procedure
998.30 / Disruption of wound, unspecified
998.31 / Disruption of internal operation (surgical) wound
998.32 / Disruption of external operation (surgical) wound
998.89 / Other specified complications of procedures not elsewhere classified
999.31 - 999.39 / Other infection due to medical care not elsewhere classified
EXCLUSIONS: Procedure Codes that exclude reporting of hospital admissions as "re-admissions" or "original admissions" using the file format specified in this document
Procedure / ICD-9-CM Procedure Code / Code Description
THA / 81.51 / Total Hip Replacement
00.74 / hip replacement bearing surface metal polyethylene
00.75 / hip replacement bearing surface metal on metal
00.76 / hip replacement bearing surface ceramic on ceramic
00.77 / hip replacement bearing surface ceramic on polyethylene
Hemiarthroplasty / 81.52 / Partial Hip Replacement with diagnosis of Rheumatoid Arthritis or Osteoarthritis of the hip or knee
with 714.0, 715.05, 715.06, 715.15, 715.16, 715.25, 715.26, 715.35, 715.36, 715.85, 715.86, 715.95, 715.96
Revision Hip Replacement / 81.53 / Revision of Hip Replacement
00.70 / Revision of hip replacement, both acetabular and femoral
00.71 / Revision of hip replacement, acetabular component
00.72 / Revision of hip replacement, femoral component
00.73 / Revision of hip replacement, acetabular liner and/or femoral head only
Hip Resurfacing / 00.85 / Resurfacing hip, total, acetabulum and femoral head
00.86 / Resurfacing hip, partial, femoral head
00.87 / Resurfacing hip, partial, acetabulum
TKA / 81.54 / Total Knee Replacement
Unicondylar Knee Replacement / 81.54 / Total Knee Replacement
Revision Knee Replacement / 81.55 / Revision Total Knee Replacement
00.80 / Revision of knee replacement, all components
00.81 / Revision of knee replacement, tibial component including tibial insert
00.82 / Revision of knee replacement, femoral component
00.83 / Revision of knee replacement, patellar component
00.84 / Revision of knee replacement, isolated revision of tibial insert

Appendix D. CJRR Phase I Final Technical Report

California Joint Replacement Registry

Phase-I

Final Report on
CJRR Technical Infrastructure

October 19, 2011

Prepared by

Sujansky & Associates, LLC

On behalf of

The Pacific Business Group on Health and

The California HealthCare Foundation

Contents

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Executive Summary

The California Joint Replacement Registry (CJRR) is a planned statewide resource for tracking joint-replacement procedures in California to improve quality and support clinical effectiveness research. Over the past 18 months, the CJRR project team designed, implemented and pilot-tested a technical infrastructure for this registry. The pilot testing entailed the collection of data from three sites over a three-month period. The registry currently contains data for over 500 joint-replacement cases, including the manufacturers and model numbers of implanted prostheses, the patients’ clinical risk factors and complications, and the patients' self-reported outcomes survey responses. This report is intended to describe the current status of the technical infrastructure and the lessons learned during its pilot testing.

The technical components of the CJRR include (1) online and file-based mechanisms to register new joint-replacement patients and planned joint-replacement cases, (2) a module for surveying patients about their conditions before and after their procedures, (3) a set of standard file formats and file-upload routines to accept peri- and post-operative clinical data from participating provider sites, (4) a module for designing, running, and distributing statistical reports to participating sites and other registry stakeholders, and (5) tools for managing users and performing other administrative tasks required by the registry. Following an eight-month period of development, acceptance testing, and de-bugging, these components have now reached a state of effectiveness and performance that provide a solid foundation for the CJRR.